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VBAC Article from TIME Magazine

Read Pamela Paul's fantastic article for Time Magazine: The Trouble with Repeat Cesareans.

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can’t find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he’s not on call the day she goes into labor? That’s why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. “One of my biggest worries is the 100-mile drive to the hospital,” she says. “It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car.”

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that “once a cesarean, always a cesarean”–an axiom thought to be outmoded in the 1990s–is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don’t allow VBACs, up from 10% in its previous survey, in 2004. ICAN’s latest findings note that another 21% of hospitals have what it calls “de facto bans,” i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.

Why the VBAC-lash? Not so long ago, doctors were actually encouraging women to have VBACs, which cost less than cesareans and allow mothers to heal more quickly. The risk of uterine rupture during VBAC is real–and can be fatal to both mom and baby–but rupture occurs in just 0.7% of cases. That’s not an insignificant statistic, but the number of catastrophic cases is low; only 1 in 2,000 babies die or suffer brain damage as a result of oxygen deprivation.
After 1980, when the National Institutes of Health (NIH) held a conference on skyrocketing cesarean rates, more women began having VBACs. By 1996, they accounted for 28% of births among C-section veterans, and in 2000, the Federal Government issued its Healthy People 2010 report proposing a target VBAC rate of 37%. Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall–even though 73% of women who go this route successfully deliver without needing an emergency cesarean.

So what happened? In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be “readily available” during a VBAC to “immediately available.” “Our goal wasn’t to narrow the scope of patients who would be eligible, but to make it safe,” says Dr. Carolyn Zelop, co-author of ACOG’s most recent VBAC guidelines.

But many interpreted the revision to mean that surgical staff must be present the entire time a VBAC patient is in labor. While major medical centers and hospitals with residents are staffed to provide this level of round-the-clock care, smaller hospitals typically rely on anesthesiologists on call. Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.

Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all. “How can a hospital say it can handle an emergency C-section due to fetal distress yet not be able to do a VBAC?” asks Dr. Mark Landon, a maternal-fetal-medicine specialist at the Ohio State University Medical Center and lead investigator of the NIH’s largest prospective VBAC study.

Part of the answer has to do with malpractice insurance. Following a few major lawsuits stemming from VBAC cases, many insurers started jacking up the price of malpractice coverage for ob-gyns who perform such births. In a 2006 ACOG survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBACs because insurance was unaffordable or unavailable; 33% said they had dropped VBACs out of fear of litigation. “It’s a numbers thing,” says Dr. Shelley Binkley, an ob-gyn in private practice in Colorado Springs who stopped offering VBACs in 2003. “You don’t get sued for doing a C-section. You get sued for not doing a C-section.”
Of course, the alternative to a VBAC isn’t risk-free either. With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta–in which the placenta attaches abnormally to the uterine wall–has increased thirtyfold in the past 30 years. “The problem is only beginning to mushroom,” says ACOG’s Zelop.

“The decline in VBACs is driven both by patient preference and by provider preference,” says Dr. Hyagriv Simhan, medical director of the maternal-fetal-medicine department of Magee-Womens Hospital of the University of Pittsburgh Medical Center. But while many obstetricians say fewer patients are requesting VBACs, others counter that the medical profession has been too discouraging of them. Dr. Stuart Fischbein, an ob-gyn whose Camarillo, Calif., hospital won’t allow the procedure, is concerned that women are getting “skewed” information about the risks of a VBAC “that leads them down the path that the doctor or hospital wants them to follow, as opposed to medical information that helps them make the best decision.” According to a nationwide survey by Childbirth Connection, a 91-year-old maternal-care advocacy group based in New York City, 57% of C-section veterans who gave birth in 2005 were interested in a VBAC but were denied the option of having one.

Zelop is among those who worry that “the pendulum has swung too far the other way,” but, she says, “I don’t know whether we can get back to a higher number of VBACs, because doctors are afraid and hospitals are afraid.” So how to reverse the trend? For one thing, patients and doctors need to be as aware of the risks of multiple cesareans as they are of those of VBACs. That is certain to be on the agenda when the NIH holds its first conference on VBACs next year. But Zelop fears that the obstetrical C-change may come too late: “When the problems with multiple C-sections start to mount, we’re going to look back and say, ‘Oh, does anyone still know how to do VBAC?’”

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Lyssa, my incision reopened too! I didn't have an infection, but it reopened (partially) one week pp and then they surgically reopened it all the way. It was just horrible! Took a good 3 months to heal and then it didn't really heal all the way and I had to have plastic surgery. The only good that came out of it was that I don't have much of a scar anymore. But, be encouraged that I have gone on to have two beautiful natural VBACs. I was really worried about UR since I'd already had one scar bust open, but my OB said "well, that was your skin, not your uterus". He was not the provider I stayed with to have my VBAC but I always was thankful for his honest response to my fear.

Cindy, I definitely think there is a link with c-sections and breastfeeding issues. Sure, some women have a c/s and have no problem b/fing, but my son refused the breast after our c/s and I eventually just gave up and my son and daughter from my VBACs have nursed great! Its just so much harder after a c/s....you're dealing with the drugs, soreness, hard to position baby around wound, etc.

This is a major event including the screening of three amazing childbirth films: Orgasmic Birth, The Business of Being Born, and Pregnant in America, and the producer of Orgasmic Birth will be at the screening as well!

Date: June 13, 2009
Location: Towne Cinema Theaters in American Fork, UT
Cost: $25
What: Screening of Orgasmic Birth, Pregnant in America, The Business of Being Born, Special Guest Speaker, Debra Pascali-Bonaro
Email: moviescreening@rawmelissa.com if you have questions

Here it is. How do you WANT to give birth? Set aside the fear for a minute. Are you ok with another c-section? Do you really want to try VBAC? The doctors and probably your relatives will warn you against a VBAC cause they think its an unnecessary risk. They will make you feel like you are endangering yourself and your child. You would never do that. You have labored before and know what it is and if something is going wrong (eg rupture) you will most likely know. You will be five minutes away from an OR, if that makes you feel "safe". But really, in childbirth, there is no such thing as safe. You can die from a c-section, you can bleed out from a uterine rupture, the L&D ward could collapse on you. Statistically all of these things are possible, but the baby is still coming so why fear it? Prepare for the worst, but figure out what is best for you. When I had my VBAC I did a lot of research cause I wanted the best chance of getting the desired outcome. In my research I found that going natural, with no interventions (pitocin, epi etc) was going to get me there. I used a doula and a midwife, because that also increased my chance of success. I used hypnobirthing to deal with the pain, and I wouldn't say I didn't feel anything, but it did give me a way to cope. And every single night I had a talk with my son in utero and told him how we were going to do it - fast and via vagina! And that's how we did it.
You seem to be a good candidate for VBAC based on the info you provided. Watch your sugar intake and try to make sure they palpate to get the baby's size. I hope you get the birth you want.

Hello, See I am aslo very short at 4`11 (under 5 feet tall) so i think the doc is saying that plays a role in the whole big baby thing too. But I think I can do the vbac. I don`t want to have the surgery if i don`t have to, the healing time is faster. with first baby we were in the hospital for 1 week cause of the infection i got. Thanks for your words of wisdom GIRLS!!!!

My first son was born c-section in 2005, he weighed 8lbs. 10oz. In December of 2008 we had our second son VBAC weighing 9lbs 10oz. We also had the big baby card waved at us. Our OB at 34 weeks backed out because of her belief that our baby was too big. We were able to find another OB willing to support us in our VBAC in a different county. When we asked our new OB how he felt about a VBAC his response was that, "Women know what they are doing. You have been doing it for thousands of years." He is absolutely right. I was told by numerous doctors I couldn't have a big baby vaginally. But I knew that I could. Stay strong and have an equally strong support team. You can do it!! Good luck!!

Lyssa- i have had 3 cesareans, after the first and the second cesareans I had little troubles getting pregnant again. Previous pregnancies were harder do to endometriosis, but had surgery for that and pregnancy came easier finally afterwards. Maybe some herbal help would be good, I took herbs the last 2 times i wanted to conceive and i think it helped. :)

Infertility can be a side-effect of a c-section. It can screw up your cycles. I would watch for signs of ovulation- or take those tests. Also, if you are not pregnant within 6 months of trying, you should think about what natural things you can do such as exercise and changing your eating habits to regulate your cycle.

Hi, everyone! I'm 31 yrs. old and my first child was born by c-section in July of 2005. After having watched The Business of Being Born and reading Your Best Birth I feel like I was jipped out of having the birth experience I would have opted for had I known I had a choice. My water broke and after not much progress they gave me PIT. 24 hours later I was still only dilated to 6 cm. I started running a fever and my baby's heart rate kept increasing, so they took me at 10:15 pm for and "emergency c-section". I had a horrible time healing and the incision ended up getting infected after part of it opened back up.

I was reading in Your Best Birth that sometimes following a c-section that in some cases it is difficult to get pregnant again due to scar tissue on the uterus. Has anyone had a difficult time getting pregnant again? My husband and I have been trying to conceive for the past 4-5 months and after reading this I started to get concerned that this might be why we're not pregnant yet.